Hospice Beats Hospital

If a doctor declares that the normal progression of your condition gives you less than six months to live, you can opt for hospice, where they don’t even try to cure your condition, but just try to make your remaining days as comfortable and meaningful as possible. According to this paper (ungated here) from the March Journal of Pain and Symptom Management, choosing a hospice makes you live longer.

We studied the difference of survival periods of terminally ill patients between those using hospices and not using hospices. … We analyzed the survival of 4493 patients from a sample of 5% of the entire Medicare beneficiary population for 1998-2002 associated with six narrowly defined indicative markers. For the six patient populations combined, the mean survival was 29 days longer for hospice patients than for nonhospice patients. The mean survival period was also significantly longer for the hospice patients with CHF, lung cancer, pancreatic cancer, and marginally significant for colon cancer (P = 0.08). Mean survival was not significantly different (statistically) for hospice vs. nonhospice patients with breast or prostate cancer.

I’m not entirely happy with they way they did their analysis, but it is certainly intruiging. Hat tip to my wife, who works in a hospice.

I’ve become interested in hospices since my wife’s maternal grandfather was diagnosed with stomach cancer and given 2-4 months to live. I had no idea how complete the services they offer is, but I’m very glad he has an alternative to hospital treatment. If we’re lucky, maybe it will help extend his life a little, though I doubt it will be long enough to save him forever.

I only skimmed the article, so maybe I missed this, but how did they factor in or account for the fact that hospitals are crawling with disease? An infectious diseases doctor once told me that if he took a sample off of a hospital wall, he’d find at least five different types of bacteria, and he would find in 99.9% (yes, I’m sure he was exaggerating that number) tests staph. Are hospices cleaner than hospitals, generally speaking? I don’t know anything about hospice. It seems that they just looked at the regression of the cancers, but I wonder what effect the overall cleanliness of hospitals versus hospices has.

douglas

And how much you wanta bet that if they did a survey they’d find that the hospice people enjoyed their time more.
This is an excellent example of how we could cut medical costs and everyone would be better off.
Tip of the hat to your wife.

Cody

I didn’t throughly read the article, but my immediate question (or thought) was that they didn’t account for the fact that there’s probably a different type of person who chooses a hospice over a hospital given the knowledge that they probably don’t have much life left. If I have my facts correct, there have been studies showing that those who are happier and more fulfilled tend to recover more quickly (or perhaps survive longer) given illness. So perhaps the people who would choose a hospice would live longer regardless of where they are, or perhaps these people have a certain predisposition that the hospice supports.

Cody, yes, the main reason for caution is the possibility of systematic differences in people who choose hospice. I tried to get access to the same data to redo their analysis better, but alas it costs many thousands of dollars.

Ryan, I would not have seen the article had my wife not pointed it out to me.

I wonder if the reason hospices are better is because doctors are killing their patients. This would not surprise me given that doctors are the third or fourth leading cause of death in the USA. They love their money too damned much.

Jon Newman

In addition to some of the thoughts already presented, one plausible contribution to longevity in hospice patients with cancer is that the “curative” treatment tends to be toxic to the body in general. Ideally, the treatment kills the cancer cells prior to the person with the cancer cells. Perhaps the ideal situation does not pan out in cases of advanced cancers.

I’d also be interested in learning of the differences between those that choose hospice care and those that don’t. That said, a patient first has to be offered hospice services in order to choose it. My understanding, which may need to be updated, is that hospice care is not automatically offered to all those that may otherwise qualify for such services.

Joseph Delaney

This is rather remarkable as I would have suspected that differential disease severity would have driven the opposite outcome. People who refuse treatment may be doing for the perfectly rational reason that their disease is worth, on average. But, if confirmed, this is a powerful argument for something that also happens to be cost effective.

Lemmus, I would work harder to control for social status proxies, and I’d do a single regression with all the data, instead of estimating the two pools separately.

douglas

Robin, data analysis is as good as the data being analyzed is relevant to the question at hand.
I worked in a hospital and one of my tasks was to resuscitate “flat-liners”
Some people were DNR (do not resuscitate)
I think to truely analyze the hospice vs. hospital experience to things need be beter understood– NDE’s (oh, it’s real)– and the change in what people are conscious of when they go from the -do resuscitate to the DNR category.

Jor

In my limitted experience, its usually patient who don’t want to head towards hospice yet. If anything, every time, I’ve witnessed one of these discussions, with a patient who isn’t ready to give up yet, its repeatedly mentioned that the hospital is a dangerous place, and when you’re approaching end-of-life the therapies remaining are more ad-hoc and definitely more dangerous.

My qualm with the study would be, I don’t think by staying in the hospital you’re trying to increase your mean survival — you’re trying to increase your probability of living to 1 or N years.

Most hospices are run as charitable organizations that do not ask for payment for their services. They provide as much care as needed (at least as far as they have resources to provide such care), regardless of how much money you have. They do ask you to donate, but to the best of my knowledge this is handled by a separate department, so the care personnel don’t know who is paying them.

So to answer your question, hospitals are nearly infinitely more expensive than hospices.

Gordon, most US hospice patients are reimbursed through Medicare and Medicaid. Charity hospices certainly do ask for such payment. But you are right that they treat patients without such coverage the same. The overall expense for hospices is less than hospitals, but less than a factor of two if I recall.

Cody’s point makes me think the title ought to have a question mark. We can only guess at the causality.
Do hospices provide patients with greater feelings of being in control? The effects of those feelings are much larger than most people realize. Studies by Langer and Rodin show that simple acts such as giving nursing home residents control over the care of a potted plant can change the six month death rate from 30% to 15%.

Jor

Peter, on the reverse side, there is a pre print in Cancer that actually shows no correlation between mood/control and outcome in a serious disease (i.e. late stage cancer). The data from the Cancer publication is from a RCT, and I believe has the most # of events (Deaths) and largest sample of all mood-outcome studies to date.

Recovering irrationalist

simple acts such as giving nursing home residents control over the care of a potted plant can change the six month death rate from 30% to 15%.

Late retirers tend to live longer, people with dependants and even pet owners are more likely to survive many serious illnesses, now this.

Peter, on the reverse side, there is a pre print in Cancer that actually shows no correlation between mood/control and outcome in a serious disease (link title: “Emotional well-being does not predict survival in head and neck cancer patients”)

Is your body programmed to shut down before it has to because your ruthless genes don’t want you outliving your usefulness to them, beyond the point you consume more in family resources than you’re worth to family fitness? Not just don’t care if you live, but would rather you didn’t.

Does feeling useful in old age counteract this effect?

If so, lives could be saved by concentrating specifically on patient perception of usefulness (modeled from an ancestral environment perspective) rather than general mood or activity. Has anyone looked at this?

Sorry if I’m being dense. This EvoPsy link does seem too obvious for someone brighter than me not to have spotted before, but I can’t find any specific mention.

Recovering irrationalist

(Plus in this case, those getting hospital attention could feel more of a burden than those in hospice, which in an ancestral environment equals consuming more resources usable by grandkids).

Jane

Instead of cherry picking subjects for a study, one should do a simple calculation of the average time spent in hospice by patients. The material for one popular hospice stated X patients since inception Y years ago – and the answer was 4 weeks (co-incidentally the Medicare limit).